Health and Social Care Committee

Inquiry into the contribution of community pharmacy to health services in Wales

 

CP 20 – Aneurin Bevan Health Board

 

RESPONSE TO THE HEALTH AND SOCIAL CARE COMMITTEE

INQUIRY INTO THE CONTRIBUTION OF COMMUNITY PHARMACY TO

HEALTH SERVICES IN WALES.

 

Aneurin Bevan Health Board (ABHB) welcomes the opportunity to provide a response to the points identified by the Health and Social Care Committee inquiry.  This response has been submitted by Jonathan Simms (Clinical Director of Pharmacy Services)

 

  1. the effectiveness of the Community Pharmacy contract in enhancing the contribution of community pharmacy to health and wellbeing services;

The Community Pharmacy contract has a real opportunity to build on public accessibility to highly trained medicines management staff, the overall structure of the contract in terms of Essential, Enhanced and Advanced services is fit for purpose to achieve improved services to patients but, with essentially a volume based remuneration in the main, progress has not been achieved as fast as we would like. In ABHB, there have been significant successes in which pharmacy services have been provided professionally, contributing to improved outcomes for patients, these successes are often overlooked and include:

·         Effective rota provision and liaison with OOH services

·         Smoking Cessation Level 2

·         Palliative Care OOH service

·         Emergency Hormonal Contraception Services

·         Supervised Administration Services which have also been adapted locally to cover DOTS (Directly Observed TB Supervision) - this service is well received by clients and providers.

·         Minor Ailments Scheme/ Torfaen medicines Administration Service (TMAS)
Torfaen Locality Only

·         Needle Exchange

·         Waste reduction Scheme – this scheme released around £50k in ABHB 2010-2011 which was used to reinforce other essential NHS services.

·         Mobilisation of services to accommodate the supply of anti-virals during the pandemic influenza scare in 2010-11

 

The above services are enhanced services, which build upon the core business of medicines management included in the essential services part of the contract, pharmacists accurately dispense, deliver and provide advice to clients every day and are heavily utilised and appreciated by the public. Pharmacy, like any other professional service, is always looking to improve and to take up the opportunities within the contract.

Consideration needs to be given to the following issues

·         There is a need to raise the national profile of pharmacies to recognise their place for first line treatment of minor ailments and medicines advice/ supply, this will ultimately improve access by decreasing unnecessary utilisation of GP services and Accident and Emergency departments.  A suite of National services needs to be developed to facilitate this e.g. National Patient Group Direction for the Urgent Supply of Repeat Medicines and Appliances and a Minor Ailment service both operate in Scotland as part of Unscheduled care demand management initiatives

·         Public Health Messages are included in the contract, but these could be optimised and better coordinated across Wales.  

·         Support for Self care is included as an essential service within the contract. It is difficult to monitor and demonstrate that this is being implemented effectively.  There is a need to provide accessible brief intervention training to key personnel to get our health messages across.  Consideration could be given to a review of whether monitoring needs to be continued.  The same difficulty in monitoring applies to the sign posting essential service.

·         Pharmacists need to work more cohesively with their GPs and develop better working relationships, there is key work around how MURs are presented to practices, repeat prescribing/dispensing services and giving out coordinated local and national messages around the use of medicines.  Better operation of the “multidisciplinary” audit should encourage co-working, but we have little evidence of this happening

·         The contract needs to offer Health Boards a route into improving services if non- compliance with the contract is identified.  Measures to deal with non-compliance could be strengthened.

·         The lack of domiciliary services for medicines use reviews allowing pharmacists to unearth huge medicines management issues in patients’ homes hampers progress and denies services to vulnerable patients.  ABHB has developed a telephone MUR quota of up to 10% of MURs by telephone, but there are opportunities for this to be addressed further within the contract. 

·         The appropriate use of Monitored Dosage System remains a contentious issue between contractors.  This is often complicated be the requirement of some Local Authorities to have these available where home care is provided.  A National solution for this would be welcomed.

 

  1. the extent to which Local Health Boards have taken up the opportunities presented by the contract to extend pharmacy services through the provision of ‘enhanced’ services, and examples of successful schemes;

ABHB has extensively introduced enhanced services across the localities and is working on equitable service provision through its Community Pharmacy Operational Group and primary care infrastructure. The enhanced services provided are indicated above, and we are about to introduce some additional services

The main problem here is the lack of a ring-fenced or allocated budget for the development of enhanced services.  Often there is no financial framework to support the development of services which hampers progress.  Despite this, we have managed to maintain and develop services.

 

  1. the scale and adequacy of ‘advanced’ services provided by community pharmacies;

Medicines concordance is a fundamental problem fo in case Boxes” – palliative care service which enhances our own unique Palliative care OOH Service

The main problem here is the lack of a ring-fenced or allocated budget for the development of enhanced services.  Often there is no financial framework to support the development of services which hampers progress.  Despite this, we have managed to maintain and develop services.

 

  1. the scale and adequacy of ‘advanced’ services provided by community pharmacies;

Medicines concordance is a fundamental problem for all Health Boards.  The Medicines Use Review service (MUR) was designed to seek out non-concordant behaviour with medicines and is generally supported by ABHB as a tool to improve clients’ access to pharmacy/medicines management input. There is little evidence of real outcomes here with concerns around the variation in how these are performed and the quality aspects of the service.

There is a lack of scrutiny, in terms of assessing quality or any post payment verification undertaken by the Health Board. This issue has been highlighted by an Internal Audit report.  However, there are limitations on what the Health Board can review under existing monitoring requirements.  This needs to be addressed.

An opportunity exists for MUR reviews to be fed back to contractors, allowing contractors to peer review their colleagues; this is what is currently happening within Neighbourhood Care networks for GPs.

There is often anecdotal information from GPs about the quality of MURs.  Where MURs work well, there are excellent relationships with GP practices.   Health Boards must get better at communicating key prescribing messages to Community Pharmacists so that we have uniformity in message from all our healthcare professionals.

 

Discussion Points

 

  1. the scope for further provision of services by community pharmacies in addition to the dispensing of NHS medicines and appliances, including the potential for minor ailments schemes;

·         The former Torfaen Local Health Board introduced a minor ailments scheme in 2006.  This has been continued in the Torfaen Locality of ABHB.  The scheme is supported by patients, GPs and pharmacists , and has the ability to improve access for patients to GP consultations if used effectively. There is scope to spread this to areas with high access demand.  A review of the existing scheme is currently being undertaken. 

·         Pharmacists are able to supply drugs through PGDs after careful assessment of patients, which may increase the scope of minor ailments schemes. There is also the capacity to relieve strain on Casualty depts. /OOH by referring on to pharmacies for service delivery especially if this were allied to a medicines service around emergency supply.

·         In all services, a simple, quick and timely mechanism of payment should be designed with the input of contractors.

·         Community Pharmacy has a place in the provision of other items such as appliances, enteral feeds, gluten free service, dressings etc and this needs further development, as currently there is a trend for outside companies to provide such items direct to patients.

 

Further scope?

·         Level 3 Smoking cessation, which would include provision of all therapies and also behavioural support at the pharmacy (all in one service) – there is evidence that this can be achieved with good quit rates, given the accessibility of pharmacies this should be considered.

·         Further developing a Waste Reduction Scheme by integrating a “Brown bag” review +/- domiciliary visit in delivery patients

·         Pharmacies should concentrate on key medicines management activities, that is our strength – consideration of structured MDS service, care home medication review/MUR/safety(processes)- in conjunction with GP – clinical pharmacy in the community

·         Developing supervised consumption service to target alcohol detox programmes, benzodiazepine users etc

·         Support the structured lifestyle requirements of NICE in partnership with GP practices

  1. the current and potential impact on demand for NHS services in primary and secondary care of an expansion of community pharmacy services, and any cost savings they may offer;

Waste reduction is key to improving efficiencies within the Health Service and medicines are no different to other areas of health.  With £50million estimated of wasted medicines each year a concerted effort needs to be made to reduce this wastage.  Reducing demand from OOH, Casualty and GP practices to improve access to effective treatment and advice.

                                                                                                                                                           

  1. progress on work currently underway to develop community pharmacy services.

 

Please see further information regarding current initiatives detailed in this response.

·         Just in case boxes – to be introduced in near future

·         MARs Service for frailty intervention

·         Further development of service provision for palliative care in ABHB

·         Aligning rotas with new community hospitals and GP access

·         Rolling out Medicines at Discharge and the concept of reconciliation

·         In ABHB we have commissioned MUR ’plus’- respiratory reviews, which is a more in depth intervention for patients on inhalers

·         Gwent Inhaler work – via the Local Practice Forum of the Royal Pharmaceutical Society  we have distributed TwoTone devices and respiratory MUR kits with the valuable assistance of Glaxo Smith Kline

·         Level 3 Smoking Business case in development

·         Rolling out national specifications for enhanced services

·         Preliminary review of needle exchange service provision compared to NICE guidance